Question 1

Nurse Beyonce is caring for a 20 lbs, 6 month-old with a 3 day history of loose watery stool, vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 40 ml/hr. Which finding should be reported to the health care provider immediately?

Accepted Answer

The concern is possible Hyperkalemia, which could occur with continued potassium administration and a decrease in urinary output since potassium is excreted via the kidneys

Question 2

A 16 month-old child was admitted to the pediatric unit. The nurse assigned to this child enters the child's room for the first time; the toddler suddenly runs to the mother and begins to cry. The nurse would initially:

Accepted Answer

During normal development, fear of strangers becomes prominent beginning around age 6-8 months. Such behaviors include clinging to parent, crying, and turning away from the stranger. These fears/behaviors extend into the toddler period and may persist into preschool.

Question 3

The nurse is caring for a 12 year-old on admission to the isolation unit. One assessment parameter that will indicate that the child has adequate fluid replacement would be:

Accepted Answer

For a child who is 12 years old age, urine output of 30ml.hour is adequate, and does not suggest fluid overload.

Question 4

Nurse Tammy is caring for a 3 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. Tammy recognizes this problem is probably due to:

Accepted Answer

Polycythemia occurs as a physiological reaction to chronic hypoxemia which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events. Cerebrovascular accidents may occur. Signs and symptoms include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures.

Question 5

A mother brings her 26 month-old to the well-child clinic. She expresses frustration due to her baby's constantly saying "NO" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need:

Accepted Answer

According to Erick Erikson's developmental theory, toddlers struggle to assert independence. They often use the word "no" even when they mean yes. This stage is called autonomy vs. shame and doubt.

Question 6

On assessment, the nurse notes that a 10-month-old child searches for and retrieves toys that disappear from view. Based on Piaget's stages of cognitive development, the nurse would recommend which of the following toys or games?

Accepted Answer

A nesting toy makes a good toy for a 10-month-old infant. At 8 to 12 months, or during the coordination of secondary reactions, the child begins to learn that objects in the environment are permanent. That is why the child searches for and retrieves toys that disappear from view. It is also during this time that infants experience separation anxiety.

Question 7

A nurse is teaching a mother with a new baby about car seats. Which of the following, if stated by the client, indicates that further teaching is needed?

Accepted Answer

Children have to be in car seats until they reach 40 to 60 pounds or until preschool. The other options are appropriate.

Question 8

A mother asks the nurse how she can prevent her child from developing recurrent otitis media. The nurse's best response is which of the following?

Accepted Answer

Respiratory infections are appropriately and immediately treated to prevent recurrent ear infections. Increasing the child's fluid intake is an effective way of treating respiratory infections. Respiratory secretions are good breeding sites for bacterial growth. The child is fed in the upright position. The other options are inappropriate.

Question 9

A mother of a 12-month-old girl asks the nurse what toys she should buy her child at this stage. Based on her understanding about the normal growth and development of a child, the nurse would suggest which of the following toys?

Accepted Answer

At 12-months old, infants like putting things in and taking things out of containers. It is suggested for the mother to provide pots and pans, blocks, and cardboard boxes that fit inside one another. Rattles are recommended at 4 months, a rubber ring at 6 months, and bright-colored mobiles at 2 months.

Question 10

A nurse is assessing an 18-month-old child. The nurse would expect the child to do which of the following actions?

Accepted Answer

A child at 18 months should be able to run and jump in place. Stacking 2 blocks should be seen at 15 months, opening doors by turning doorknobs at 36 months, and climbing stairs alone with both feet on the same step at the same time at 24 months.

Question 11

The nurse is developing a teaching plan for a patient who just received an inserted permanent pacemaker. Which of the following concepts should the nurse teach the patient?

Accepted Answer

It is important for the nurse to teach the patient to avoid tight clothing or direct pressure on the site of the pacemaker as part of the teaching plan. It is also important to avoid magnetic resonance imaging (MRI) scans, but CT scans are fine.

Question 12

A patient comes to the Cardiovascular Care Unit with a blood pressure of 94/68, a heart rate of 124 and chest pain rated as 8/10. The patient has already taken one 0.04 mg tablet of Nitroglycerin five minutes ago. What should the nurse do next?

Accepted Answer

The next thing the nurse should do with this patient is to give an additional dose of 0.04 mg tablet of Nitroglycerin. Patients can take up to three sublingual Nitroglycerin tablets within 15 minutes. It may take 5 to 10 minutes to relieve chest pain. After administering the Nitroglycerin, the nurse can take vital signs and obtain an EKG. However, it is primarily important to relieve the chest pain.

Quiz 4: Adult Critical Care Registered Nurse